palliative care key performance indicator metadata 2017 · data quality issues data quality issues...

Palliative Care Key Performance Indicator Metadata 2017

1

1 KPI Title Access to specialist inpatient bed within seven days (during the reporting month)

2 KPI Description This is a calculation of the number of patients who were admitted to a specialist inpatient palliative care bed within seven days of referral or request for transfer expressed as a

proportion of all patients admitted to a specialist inpatient bed in the reporting month multiplied by 100.

For the purpose of this metric return, the services submit the relevant numbers with the percentage calculated by the Business Information Unit (BIU).

A referral is defined as a request for a service to be provided to a specific person. It is usually in writing but not necessarily so.

An enquiry or request for information is not in itself a referral. If an enquiry subsequently leads to a request for service, the latter is the referral.

There are two types of referral - 1) Active; 2) Inactive (pending or deferred or prospective).

1) Active: An active patient referral is in respect of a patient who is available to immediately take up the offer of service. The term active is used to distinguish referrals that request a

service to start as soon as possible from the common situation in palliative care whereby referrals are made in a prospective manner i.e. made in advance for a service that may be

required at some stage in the future.

2) Inactive: An inactive patient referral is in respect of a patient who is not available to take up the offer of service. These referrals should not be considered active until a service has

been formally requested and the patient is available to take up the service.

Following referral / request for transfer the patient is triaged / assessed by the specialist palliative care clinical lead before suitability for admission is agreed.

Wait time (in number of days) to admission is calculated from the date of referral / request for transfer to the date of admission to the specialist palliative care inpatient unit . Each

day (inclusive of weekends and bank holidays) that the patient waits to be admitted is counted, with wait times categorised as follows: 0-7 days; 8-14 days; 15-28 days; greater than

28 days.

Note it is important not to include prospective (ie. inactive, pending, or deferred) referrals as active referrals when wait times are being calculated as the time of initial prospective

referral will artificially lengthen wait times.

KPI Rationale To determine the proportion (percentage) of patients accessing specialist inpatient beds within seven days.

Indicator Classification Please tick which Indicator Classification this indicator applies to, ideally choose one classification (in some cases you may need to choose two).

☑ Person Centred Care, ☑ Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information,

□ Workforce, □ Use of Resources, □ Governance, □Leadership and Management

4 KPI Target 2017 NSP 2017 Target - 98%

5 KPI Calculation Count the number of patients admitted to a specialist inpatient bed within seven days of assessment / request for transfer and express it as a proportion of the overall number of

patients admitted to specialist inpatient beds in the reporting period and multiply by 100. Example, 200 patients were admitted to specialist inpatient beds in the reporting month

i.e.of these 154 patients waited 0-7 days, 35 patients waited 8-14 days, 5 patients waited 15-28 days & 6 patients waited >28 days for admission.

Calculation for access within seven days is as follows: 154 / (154+35+5+6) →154/(200) → 0.770, multiplied by 100 = 77%.

For the purpose of this metric return, the services submit the relevant numbers with the percentage calculated by the BIU.

Data Source Data is sourced by the specialist palliative care units who forward it to their Community Healthcare Organisation (CHO). The CHO submits the validated data to the BIU Community

Healthcare Team.

Data Completeness Data completeness is expected at 100%.

Data Quality Issues Data quality issues are addressed as they arise along the data pathway.

7 Data Collection Frequency Indicate how often the data to support the KPI will be collected:

□ Daily □ Weekly ☑ Monthly □ Quarterly □ Bi-annually □ Annually □Other – give details:

8 Tracer Conditions The number of people admitted to specialist palliative care inpatient units and wait times for admission in particular wait time 0-7 days.C21.

9 Minimum Data Set The number of people admitted to specialist palliative care inpatient units and wait times for admission in particular wait time 0-7 days.

10 International Comparison http://www.ncpc.org.uk/mds

11 KPI Monitoring KPI will be monitored on a (please indicate below) basis:

□ Daily □ Weekly ☑Monthly □ Quarterly □ Bi-annually □ Annually □ Other – give details:

The validated data is monitored by the National Lead for Palliative Care, the CHO Chief Officer and the Primary Care Division Operations Team via performance meetings.

12 KPI Reporting Frequency Indicate how often the KPI will be reported:

□ Daily □ Weekly ☑ Monthly □ Quarterly □ Bi-annually □ Annually □ Other – give details:

13 KPI report period Indicate the period to which the data applies:

☑ Current (e.g. daily data reported on that same day of activity, monthly data reported by the 10th of the following month)

□ Monthly in arrears (June data reported in July)

□ Quarterly in arrears (quarter 1 data reported in quarter 2)

□ Rolling 12 months (previous 12 month period)

14 KPI Reporting Aggregation Indicate the level of aggregation – for example over a geographical location:

☑ National ☑ CHO ☑ LHO Area □ Hospital

□ County ☑ Institution □ Other – give details:

15 KPI is reported in which

reports ?

Indicate where the KPI will be reported:

☑ Performance Report □Other – give details:

16 Web link to data http://www.hse.ie/eng/services/publications/

17 Additional Information

Information Analyst : Geraldine Littler, Business Information Unit- Palliative Care & Social Inclusion, Planning and Business Information (PBI) 046 9251330

Email:[email protected]

National Lead: Sheilagh Reaper-Reynolds Email: [email protected]

John Hennessy, National Director, Primary Care Division, Health Service Executive.

Primary Care - Palliative Care Inpatient Palliative Care Services

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Contact details for Data Manager /

Specialist Lead

National Director and Division

http://www.ncpc.org.uk/mds

1 KPI Title Number accessing specialist inpatient bed within seven days (during the reporting month)

2 KPI Description This is a count of the number of patients who were admitted to a specialist palliative care inpatient unit within seven days of referral or request for transfer to the date of admission A

referral is defined as a request for a service to be provided to a specific person. It is usually in writing but not necessarily so.There are two types of referral: 1) Active; 2) Inactive

(pending or deferred or prospective).

1) Active: An active patient referral is in respect of a patient who is available to immediately take up the offer of service. The term active is used to distinguish referrals that request a



2) Inactive: An inactive patient referral is in respect of a patient who is not available to take up the offer of service straight away. This referral group should not be considered to be

active until a service has been formally requested and the patient is available to take up the service.


Wait time (in number of days) to admission is calculated from the date of referral / request for transfer to the date of admission to the specialist palliative care inpatient unit. Each day

(inclusive of weekends and bank holidays) that the patient waits to be admitted is counted, with wait times categorised as follows: 0-7 days; 8-14 days; 15-28 days; greater than 28

days.



KPI Rationale To determine the number of patients accessing specialist inpatient beds within seven days of referral / request for transfer


☑ Person Centred Care, ☑ Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □ Use of Resources, □ Governance, □Leadership and

Management

4 KPI Target 2017 NSP 2017 Target National - 3,555

CHO 1 - 355, CHO 2 - 333, CHO 3 - 593, CHO 4 - 728, CHO 5 - 92, CHO 6 -152, CHO 7 -679, CHO 8 - (no service), CHO 9 -623

5 KPI Calculation Count the total number of patients accessing specialist palliative care inpatient beds within seven days of referral / request for transfer.


Healthcare Team.





8 Tracer Conditions The number of people admitted to specialist palliative care inpatient units within seven days of referral / request for transfer.

9 Minimum Data Set The number of people admitted to specialist palliative care inpatient units within seven days of referral / request for transfer.




The validated data is monitored by the National Lead for Palliative Care, the CHO Chief Officer and the Primary Care Division Operations Team via performance meetings. A18












reports ?









6



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Specialist Lead


1 KPI Title Access to specialist palliative care inpatient bed from eight to 14 days (during the reporting month)

2 KPI Description This is a calculation of the number of patients who were admitted to a specialist inpatient palliative care bed within eight to 14 days of referral or request for transfer expressed as a

proportion of all patients admitted to a specialist inpatient bed in the reporting month multiplied by 100.


A referral is defined as a request for a service to be provided to a specific person. It is usually in writing but not necessarily so. There are two types of referral: 1) Active; 2) Inactive

(pending or deferred or prospective).

1) Active: An active patient referral is in respect of a patient who is available to immediately take up the offer of service.The term active is used to distinguish referrals that request a



2) Inactive: An inactive patient referral is in respect of a patient who is not available to take up the offer of service straight away. This referral group should not be considered to be

active until a service has been formally requested and the patient is available to take up the service.


Wait time (in number of days) to admission is calculated from the date of referral / request for transfer to the date of admission to the specialist palliative care inpatient unit. Each

day (inclusive of weekends and bank holidays) that the patient waits to be admitted is counted, with wait times categorised as follows: 0-7 days; 8-14 days; 15-28 days; greater than

28 days.



KPI Rationale To determine the proportion (percentage) of patients accessing specialist inpatient beds between eight to 14 days of referral / request for transfer.


☑ Person Centred Care, ☑ Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information,

□ Workforce, □ Use of Resources, □ Governance, □Leadership and Management


5 KPI Calculation Count the number of patients admitted to a specialist inpatient bed within eight to 14 days of referral / request for transfer and express it as a proportion of the overall number of

patients admitted to specialist inpatient beds in the reporting period and multiply by 100. Example, 200 patients were admitted to specialist inpatient beds in the reporting month, of

these 154 patients waited 0-7 days, 35 patients waited 8-14 days, 5 patients waited 15-28 days & 6 patients waited >28 days for admission.

Calculation for access between eight to 14 days is as follows: (35) / (154+35+5+6) → 35 / (200) → 0.175, multiplied by 100 = 17.5%



Healthcare Team.





8 Tracer Conditions The number of people admitted to specialist palliative care inpatient units and wait times for admisssion in particular wait time 8-14 days.

9 Minimum Data Set The number of people admitted to specialist palliative care inpatient units and wait times for admission in particular wait time 8-14 days.
















reports ?








John Hennessy, National Director, Primary Care Division, Health Service Executive. National Director and Division


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Specialist Lead


1 KPI Title Percentage of patients triaged within one working day of referral (Inpatient Unit)

2 KPI Description This is a calculation of the number of patients triaged within one working day of referral or request for transfer expressed as a proportion of all patients referred / requesting transfer

in the reporting month multiplied by 100.


A referral is defined as a request for a service to be provided to a specific person. It is usually in writing but not necessarily so. An enquiry or request for information is not in itself a

referral. If an enquiry subsequently leads to a request for service, the latter is the referral.

Triage is defined as the examination of the patient referral form, patient notes, scans and reports to ascertain the appropriate timeframe for delivery of specialist palliative care

inpatient services to a patient. All patients are triaged. The triage categories are as follows:

Category 1: This is an urgent referral where the patient is in severe physical, psychosocial or spiritual distress and not responding to current management or standard protocols of

care or rapidly deteriorating or imminently dying

Category 2: This is an early referral where the patient has poorly controlled symptoms or a prognosis of only short weeks or acute psychosocial stressors

Category 3: This is a routine referral where the patient’s current symptoms and available supports or care are such that the situation is reasonably stable. The patient triaged to

Category 3 should be visited within 2 weeks from receipt of referral.

Time to triage is calculated by counting the number of days (working days i.e. Monday to Friday excluding week ends and bank holidays i.e. based on 5 / 7 days of service

provision) from receipt of referral, or request for patient transfer into service, to date of triage.

KPI Rationale To determine the proportion (percentage) of referred patients triaged within a specific and appropriate timeframe of one working day.


☑ Person Centred Care, ☑ Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce,

□ Use of Resources, □ Governance, □Leadership and Management


5 KPI Calculation Count the number of patients triaged within one working day of referral or request for transfer and express it as a proportion of all patients referred / requesting transfer in the

reporting month and multiply by 100.

Example: Total number of referrals received = 90,

Total number of these referrals triaged within 1 working day = 78

Calculation: (78/90) x100 = 86.7%



Healthcare Team.





8 Tracer Conditions The number of people triaged within one working day of referral and the total number of people referred / requesting transfer in the reporting month.

9 Minimum Data Set The number of people triaged within one working day of referral and the total number of people referred / requesting transfer in the reporting month.

10 International Comparison http://www.ncpc.org.uk/mds-annual-questionnaires







□ Current (e.g. daily data reported on that same day of activity, monthly data reported by the 10th of the following month)

☑ Monthly in arrears (June data reported in July)





□County ☑ Institution □ Other – give details:


reports ?


☑ Performance Report □ Other – give details:







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Specialist Lead


http://www.ncpc.org.uk/mds-annual-questionnaires

1 KPI Title Number of patients in receipt of treatment in specialist palliative care inpatient units (during the reporting month)

2 KPI Description This is a count of the total number of patients who received treatment in a specialist palliative care inpatient unit during the reporting month. All patients are to be counted with each

patient counted once only. If a patient is referred twice then they are still counted once only.

3 KPI Rationale To determine the total number of patients who received a service in a specialist palliative care inpatient unit in the reporting month.




4 KPI Target 2017 DOP 2017 Target National - 494

CHO 1 - 41, CHO 2 - 45, CHO 3 - 70, CHO 4 - 127, CHO 5 - 7, CHO 6 - 32, CHO 7 - 82, CHO 8 - (no service), CHO 9 - 90

5 KPI Calculation Count the number of patients who received treatment in a specialist palliative care inpatient unit in the reporting month.

Data Source Data is sourced by the specialist palliative care units who forward it to their Community Healthcare Organisation (CHO). The CHO submits the validated data to the Business

Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions Patients in receipt of specialist palliative inpatient treatment in the reporting month.

9 Minimum Data Set Patients in receipt of specialist palliative inpatient treatment in the reporting month.








☑ Current (e.g. daily data reported on that same day of activity,monthly data reported by the 10th of the following month)








reports ?










Specialist Lead


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1 KPI Title Number of new patients seen or admitted to the specialist palliative care service (monthly cumulative)

2 KPI Description This is a count of the total number of new (first time ever) patients who received (i.e. were seen in or admitted to) a specialist inpatient palliative care service during the reporting

month. A patient can only be 'new' on the first time referred. Patients discharged and then re-referred, regardless of timeframe, are not to be considered a new patient but a re-

referral.

KPI Rationale To determine the number of new patients accessing the service. This will inform service delivery and decisions going forward especially with regard to service provision / prediction

of service provision.




4 KPI Target 2017 DOP 2017 Target National - 3,110

CHO 1 - 270, CHO 2 - 304, CHO 3 - 400, CHO 4 - 790, CHO 5 - 40, CHO 6 - 200, CHO 7 - 496, CHO 8 - (no service), CHO 9 - 610

5 KPI Calculation Count all new (first time ever) patients who received a service in the specialist palliative care inpatient unit during the reporting month.





7 Data Collection Frequency Indicate how often the data to support the KPI will be collected: □ Daily □

Weekly ☑ Monthly □ Quarterly □ Bi-annually □ Annually □Other – give details:

8 Tracer Conditions New patients seen or admitted to specialist palliative care inpatient services for the first time ever in the reporting period.

9 Minimum Data Set New patients seen or admitted to specialist palliative care inpatient services for the first time ever in the reporting period.
















reports ?










Specialist Lead



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1 KPI Title Number of admissions to specialist palliative care inpatient units (monthly cumulative)

2 KPI Description This is a count of the total number of admissions of patients who were deemed appropiate for admission and to receive treatment in a specialist palliative care inpatient unit /

service / hospice during the reporting month. Each admission is counted. If a patient is admitted twice during the reporting period then they are counted twice.

KPI Rationale To determine the total number of admissions to specialist palliative care inpatient units during the month.





CHO 1 - 360, CHO 2 - 350, CHO 3 - 580, CHO 4 - 910, CHO 5 - 75, CHO 6 - 250, CHO 7- 620, CHO 8 - (no service), CHO 9 - 670

5 KPI Calculation Count the total number of admissions for specialist palliative care inpatient stays during the reporting month.







8 Tracer Conditions New patients seen or admitted to specialist palliative care inpatient services for the first time ever in the reporting period.

9 Minimum Data Set New patients seen or admitted to specialist palliative care inpatient services for the first time ever in the reporting period

10 International Comparison Yes. E.g. http://www.ncpc.org.uk/mds















reports ?










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Specialist Lead

1 KPI Title Percentage of patients with a multidisciplinary care plan documented within five working days of initial assessment (Inpatient Unit)

This is a calculation of the number of patients in receipt of specialist palliative care inpatient services who having been discussed at a multidisciplinary team meeting within five days

of initial assessment have a documented multidisciplinary care plan as a result of this discussion expressed as a proportion of all patients admitted to a specialist palliative care

inpatient unit during the reporting period multiplied by 100. For the purpose of this metric return, the services submit the relevant numbers with the percentage calculated by

the Business Information Unit (BIU). It does not include patients who are waiting for services or patients who are refusing a service or are deemed inappropriate for the service.

The constitution of multi disciplinary teams (mdts) vary across services. A mdt is any group of health care workers who are members of different disciplines each providing specific

services to the patient. The gold standard mdt is described in the 2001 NACPC report but this comprehensive mdt model is not compulsory to fulfil this metric. A multidisciplinary care

plan is defined as: a comprehensive plan required to meet the needs of the individual and based on a holistic needs assessment covering the four domains of palliative care:

(a) physical well-being

(b) social and occupational well-being

(c) psychological well-being

(d) spiritual well-being

This plan is a reflection of the discussions held during the mdt meeting and is not filled out independently by disciplines. A sample template care plan form is available

at.https://www.hse.ie/eng/about/Who/clinical/natclinprog/palliativecareprogramme/Resources/a3poster.pdf

Time to documentation of the care plan is calculated by counting the number of working days (Monday to Friday excluding weekends and bank holidays, and is based on 5/7 days of

service provision) from initial assessment to documentation of the multidisciplinary care plan.

KPI Rationale To determine the proportion (percentage) of patients who have been discussed at a multidisciplinary team meeting within a specified timeframe of five working days from initial

assessment and have a documented multidisciplinary care plan as a result of this discussion.




Count the number of patients in an specialist palliative care inpatient unit discussed at a mdt meeting within five working days of initial assessment who have a documented

multidisciplinary care plan as a result of this discussion and express it as a proportion of all patients admitted to a specialist palliative care inpatient unit in the reporting period and

multiply by 100.

Example: Total number of patients admitted to a specialist palliative care inpatient unit = 90

Total number of these who have been discussed at a mdt meeting within five working days of admission and have a documented multidisciplinary care plan as a result of this

discussion = 78

Calculation: (78 / 90) x100 = 86.7%



Healthcare Team.



7 Data Collection Frequency Indicate how often the data to support the KPI will be collected: □ Daily □ Weekly ☑ Monthly □ Quarterly □ Bi-annually □ Annually □Other – give details:

8 Tracer Conditions The number of patients admitted to specialist palliative care inpatient units who have a documented multidisciplinary care plan within five working days of initial assessment as a

result of discussion at a mdt meeting and the overall number of patients admitted to a specialist palliative care inpatient unit.

9 Minimum Data Set The number of patients discussed at a mdt within five working days of initial assessment in an in-patient unit with a documented multidisciplinary care plan as a result of this

discussion and the overall number of patients admitted to a specialist palliative care inpatient unit.
















reports ?









KPI Target 2017 NSP 2017 Target - 90%

5 KPI Calculation

6


Specialist Lead



2 KPI Description

3

4

https://www.hse.ie/eng/about/Who/clinical/natclinprog/palliativecareprogramme/Resources/a3poster.pdf




http://www.hse.ie/eng/services/publications/

1 KPI Title Number of patients in receipt of care in designated palliative care support beds (during the reporting month)

2 KPI Description This is a count of the number of patients in receipt of care in a designated palliative care support bed in the reporting month. A palliative

care support bed (Level 2 or Intermediate Care bed) is a bed / service providing an intermediate level of inpatient palliative care for

patients in a local environment. A person who requires respite, control of symptoms or end of life care (cancer and non-cancer) may be

deemed suitable for admission to a palliative care support bed. Each patient is counted once only in the reporting month.

KPI Rationale To determine and monitor the total number of patients who received care in designated palliative care support beds during the month.

Indicator Classification Please tick which Indicator Classification this indicator applies to, ideally choose one classification (in some cases you may need to

choose two).

☑ Person Centred Care, ☑Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □

Use of Resources, □ Governance, □ Leadership and Management


CHO 1 - 21, CHO 2 - 4, CHO 3 - 19, CHO 4 - 31, CHO 5 - 33, CHO 6 - 13, CHO 7- 40, CHO 8 - 15, CHO 9 - 0

5 KPI Calculation Count the total number of patients who received care in a designated palliative care support bed in the reporting month.

Data Source Data in relation to specialist palliative care units and designated beds is submitted to the Community Healthcare Organisation (CHO).

The CHO submits the validated data to the Business Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions Number of patients who received care in designated palliative care support beds in the reporting month.

9 Minimum Data Set Number of patients who received care in designated palliative care support beds in the reporting month.

10 International Comparison No


□ Daily □ Weekly ☑ Monthly □ Quarterly □ Bi-annually □ Annually ☑Other – give details

The validated data is monitored by the National Lead for Palliative Care, the CHO Chief Officer and the Primary Care Division Operations

Team via performance meetings.





□Monthly in arrears (June data reported in July)





□County □ Institution □ Other – give details:


reports ?


☑ Performance Report (NSP) □Other – give details:



Information Analyst : Geraldine Littler, Business Information Unit- Palliative Care & Social Inclusion, Planning and Business Information

(PBI) 046 9251330 Email:[email protected]



3

Primary Care - Palliative Care Intermediate Care


Specialist Lead


6

1 KPI Title Number of patients in receipt of specialist palliative day care services (during the reporting month)

2 KPI Description The is a count of the number of patients (each patient is counted once only) in receipt of specialist palliative day care / day hospice

services during the reporting month. Specialist palliative day care / day hospice services are provided to patients in a day care / day

hospice setting. All patients in receipt of specialist palliative day care / day hospice services on the first day of the month and all new

patients who attend specialist palliative day care during the month are included.

KPI Rationale To determine the total number of patients who received specialist palliative day care / day hospice services during the reporting month.


choose two).

☑ Person Centred Care, ☑ Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □ Use of

Resources, □ Governance, □Leadership and Management


CHO 1 - 15, CHO 2 - 35, CHO 3 - 40, CHO 4 - 120, CHO 5 - 0, CHO 6 - 40, CHO 7 - 40, CHO 8 - 0, CHO 9 - 65

5 KPI Calculation Count the total number of patients (each patient is counted once only) who received specialist palliative day care / day hospice services

during the reporting month.

Data Source Data is sourced by the specialist palliative care units who forward it C19to their Community Healthcare Organisation (CHO). The CHO

submits the validated data to the Business Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions The number of patients in receipt of specialist palliative care services in a day care / day hospice setting.

9 Minimum Data Set The number of patients (people) in receipt of specialist palliative care services in a day care / day hospice setting.




The validated data is monitored by the National Lead for Palliative Care, the CHO Chief Officer and the Primary Care Division

Operations Team via performance meetings.










□ County □ Institution □ Other – give details:


reports ?





Information Analyst : Geraldine Littler, Business Information Unit- Palliative Care & Social Inclusion, Planning and Business

Information (PBI) 046 9251330 Email:[email protected]


John Hennessy, National Director, Primary Care Division, Health Service Executive. National Lead and Division

Primary Care - Palliative Care Day Care

3


Specialist Lead

6


1 KPI Title Number of new patients who received specialist palliative day care services (monthly cumulative)

2 KPI Description This is a count of the number of new patients (each patient is counted once only) in receipt of specialist palliative day care / day hospice

services, for the first time ever, during the reporting month. A patient can only be 'new' on the first time referred. Patients discharged

and then re-referred, regardless of timeframe, are not to be considered a new patient but a re-referral. All new patients who attend

specialist palliative day care services for the first time ever during the month are included. Specialist palliative day care / day hospice is

care provided to patients in a day care / day hospice setting.

KPI Rationale To determine the total number of new patients who received specialist palliative day care / day hospice during the month.


choose two).




CHO 1-C6490, CHO 2 - 65, CHO 3 - 120, CHO 4 - 375, CHO 5 - 0, CHO 6 - 120, CHO 7 - 120, CHO 8 - 0, CHO 9 - 120

5 KPI Calculation Count the total number of new patients who received specialist palliative day care / day hospice services during the reporting month.

Data Source Data is sourced by the specialist palliative care units who forward it to their Community Healthcare Organisation (CHO). The CHO

submits the validated data to the Business Information Unit (BIU) Community Healthcare Team.

Data Completeness Data completeness is expected at 100%.C40




8 Tracer Conditions The number of new people in receipt of specialist palliative care services in a day care / day hospice setting for the first time ever.

9 Minimum Data Set The number of new people in receipt of specialist palliative care services in a day care / day hospice setting for the first time ever.




The validated data is monitored by the National Lead for Palliative Care, the CHO Chief Officer and the Primary Care Division

Operations Team via performance meetings.




☑Current (e.g. daily data reported on that same day of activity, monthly data reported by the 10th of the following month)








reports ?





Information Analyst : Geraldine Littler, Business Information Unit- Palliative Care & Social Inclusion, Planning and Business

Information (PBI) 046 9251330 Email:[email protected]



Primary Care - Palliative Care Day Care


Specialist Lead

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1 KPI Title Access to specialist palliative care services in the community provided within seven days (normal place of residence) (during the reporting

month)

2 KPI Description This is a calculation of the number of patients accessing specialist palliative care services in their normal place of residence, in the

community, within seven days of referral or request for transfer expressed as a proportion of the overall number of patients accessing these

services within the reporting month multiplied by 100. For the purpose of this metric return, the services submit the relevant numbers

with the percentage calculated by the Business Information Unit (BIU).

Home is defined as the patient's normal place of residence i.e. where he / she lives, and may include his / her home, carers home, nursing

home, community nursing unit, community hospital, district hospital etc.

A referral is defined as a request for a service to be provided to a specific person. It is usually in writing but not necessarily so. An enquiry

or request for information is not in itself a referral. If an enquiry subsequently leads to a request for service, the latter is the referral.


1) Active: An active patient referral is in respect of a patient who is available to immediately take up the offer of service. The term active is

used to distinguish referrals that request a service to start as soon as possible from the common situation in palliative care whereby referrals

are made in a prospective manner i.e. made in advance for a service that may be required at some stage in the future.

2) Inactive: An inactive patient referral is in respect of a patient who is not available to take up the offer of service straight away. This referral

group should not be considered to be active until a service has been formally requested and the patient is available to take up the service.

Following referral /

request for transfer the patient is triaged / assessed by the specialist palliative care clinical lead before suitability for services in the

community is agreed.

Time to

access services is counted as the number of days (all days) from referral, or request for transfer, to the date of the first face to face home

care visit. There are four wait time categories i.e. 0-7 days; 8-14 days; 15-28 days; greater than 28 days.

Note it is

important not to include prospective (ie.inactive, pending, or deferred) referrals as active referrals when wait times are being calculated as

the time of initial prospective referral will artificially lengthen wait times.

KPI Rationale To determine the proportion (percentage) of patients accessing specialist palliative care services in the community within seven days of

referral / request for transfer.

Indicator Classification Please tick which Indicator Classification this indicator applies to, ideally choose one classification (in some cases you may need to choose

two). ☑ Person Centred Care,

☑ Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce,



5 KPI Calculation Count the number of patients who accessed specialist palliative care services in their normal place of residence, in the community, within

seven days of referral and express it as a proportion of the overall number of patients accessing these services within the reporting period

and multiply by 100.

Example 200 patients accessed specialist palliative care services in the community in the reporting month, of these 154 patients waited 0-7

days, 35 patients waited 8-14 days, 5 patients waited 15-28 days & 6 patients waited >28 days for first face to face visit.

Calculation for access within seven days is as follows: 154 / (154+35+5+6) →154 / (200) → 0.770, multiplied by 100 = 77%.


Data Source Data is sourced by the specialist palliative care units who forward it to their Community Healthcare Organisation (CHO). The CHO submits

the validated data to the BIU Community Healthcare Team.





8 Tracer Conditions The overall number of people accessing specialist palliative care services in the community and wait times to access these services in

particular wait time 0 - 7 days.

9 Minimum Data Set The overall number of people accessing specialist palliative care services in the community and wait times to access these services in


















reports ?










Specialist Lead

Primary Care - Palliative Care Community Palliative Care Services

6

3


1 KPI Title Access to specialist palliative care services in the community provided to patients in their place of residence within 8 - 14 days (normal place

of residence) (during the reporting month)


community, within eight to 14 days of referral or request for transfer expressed as a proportion of the overall number of patients accessing

these services within the reporting month multiplied by 100. For the purpose of this metric return, the services submit the relevant

numbers with the percentage calculated by the Business Information Unit (BIU).

Home is defined as the patient's normal place of residence i.e. where he / she lives, and may include his / her home, a carers home, nursing


A referral is defined as a request for a service to be provided to a specific person. It is usually in writing but not necessarily so. An enquiry or

request for information is not in itself a referral. If an enquiry subsequently leads to a request for service, the latter is the referral.



used to distinguish referrals that request a service to start as soon as possible based on the common situation in palliative care whereby

referrals are made in a prospective manner i.e. made in advance for a service that may be required at some stage in the future.



Following referral / request for transfer the patient is triaged / assessed by the specialist palliative care clinical lead before suitability for

services in the community is agreed.

Time to access

services is counted as the number of days (all days) from referral, or request for transfer, to the date of the first face to face home care visit.

There are four wait time categories i.e. 0-7 days; 8-14 days; 15-28 days; greater than 28 days.

Note it is

important not to include prospective (ie. inactive, pending, or deferred) referrals as active referrals when wait times are being calculated as

the time of initial prospective referral will artificially lengthen wait times.

KPI Rationale To determine the proportion (percentage) of patients having a first face to face specialist palliative care visit in the community within eight to

14 days of referral / request for transfer.


two).



4 KPI Target 2017 DOP 2017 Target - 3%


eight to 14 days of referral or request to transfer and express it as a proportion of the overall number of patients accessing these services

within the reporting period and multiply by 100.



Calculation for access within 8-14 days is as follows: (35) / (154+35+5+6) → 35 / (200) → 0.175, multiplied by 100 = 17.5%











particular wait time 8 -14 days.

















reports ?









3

6



Specialist Lead


1 KPI Title Access to specialist palliative care services in the community provided to patients in their place of residence within 15+ days (normal place of

residence) (during the reporting month)


community, within 15+ days of referral, or request for transfer, expressed as a proportion of the overall number of patients accessing these

services within the reporting month multiplied by 100. For the purpose of this metric return, the services submit the relevant numbers

with the percentage calculated by the Business Information Unit (BIU).

Home is defined as the patient's normal place of residence i.e. where he / she lives, and may include his / her home, a carers home, nursing






used to distinguish referrals that request a service to start as soon as possible based on the common situation in palliative care whereby

referrals are made in a prospective manner i.e. made in advance for a service that may be required at some stage in the future.



Following referral / request for transfer the patient is triaged / assessed by the specialist palliative care clinical lead before suitability for

services in the community is agreed.

Time to

access services is counted as the number of days (all days) from referral, or request for transfer, to the date of the first face to face home

care visit. There are four wait time categories i.e. 0-7 days; 8-14 days; 15-28 days; greater than 28 days.

Note it is important not to include prospective (ie. inactive, pending, or deferred) referrals as active referrals when wait times are being

calculated as the time of initial prospective referral will artificially lengthen wait times.

3 KPI Rationale To determine the proportion (percentage) of patients having a first face to face specialist palliative care visit in the community within 15+ days

of referral / request for transfer.


two).



4 KPI Target 2017 DOP 2017 - Target: 2%


15+ days of referral / request for transfer and express it as a proportion of the overall number of patients accessing these services within the

reporting period and multiply by 100.



Calculation for access within 15+ days is as follows (5 + 6) / (154+35+5+6) →11 / (200) →0.055, multiplied by 100 = 5.5%





Data Quality IssuesData quality issues are addressed as they arise along the data pathway.




particular wait times 15 -28 days and >28 days.


particular wait times 15 -28 days and >28 days.

















reports ?




17 Additional InformationInformation Analyst : Geraldine Littler, Business Information Unit- Palliative Care & Social Inclusion, Planning and Business Information






Specialist Lead

6


1 KPI Title Percentage of patients triaged within one working day of referral (Community)

2 KPI Description This is a calculation of the number of patients triaged within one working day of referral or request for patient transfer to service expressed as

a proportion of all patients referred / requesting transfer in the reporting month multiplied by 100.



Triage is defined as the examination of the patient referral form, patient notes, scans and reports to ascertain the appropriate timeframe for

delivery of specialist palliative care in the community. All patients are triaged. The triage categories are as follows:

Category 1: This is an urgent referral where the patient is in severe physical, psychosocial or spiritual distress and not responding to current

management or standard protocols of care or rapidly deteriorating or imminently dying

Category 2: This is an early referral where the patient has poorly controlled symptoms or a prognosis of only short weeks or acute

psychosocial stressors

Category 3: This is a routine referral where the patient’s current symptoms and available supports or care are such that the situation is

reasonably stable. The patient triaged to Category 3 should be visited within 2 weeks from receipt of referral.

Time to triage is calculated by counting the number of days (working days i.e. Monday to Friday excluding week ends and bank holidays i.e.

based on 5 / 7 days of service provision) from receipt of referral, or request for patient transfer into service, to date of triage.

KPI Rationale To determine the proportion (percentage) of referred patients triaged within the specific and appropriate timeframe of one working day.


two).




5 KPI Calculation Count the number of patients triaged within one working day of referral / request for transfer, and express it as a proportion of all patients

referred / requesting transfer in the reporting month.

Example: Total number of referrals / requests for transfer received = 90

Total number of these referrals triaged within 1 working day= 78

Calculation: (78 / 90) x 100 = 86.7%








8 Tracer Conditions The number of people triaged within one working day of referral / request for transfer and the total number of partients referred / requesting

transfer in the reporting month.

9 Minimum Data Set The number of people triaged within one working day of referral / request for transfer and the total number of partients referred / requesting

transfer in the reporting month.

















reports ?









6

3


Specialist Lead



1 KPI Title No. of patients who received treatment in their normal place of residence

2 KPI Description This is a count of the total number of patients who received specialist palliative care in the community during the reporting month. Specialist

palliative care in the community is care provided to patients in their normal place of residence i.e. their home, carers home, nursing home,

community nursing unit, community hospital, district hospital etc. All patients in receipt of specialist palliative care in the community (home

care) on the first day of the month and all new patients who received a first face to face visit during the month are included with each patient

counted once only in the reporting month.

KPI Rationale To determine the total number of patients who received specialist palliative care in the community (home care) during the reporting month.


two).





5 KPI Calculation Count the total number of patients who received specialist palliative care in the community (home care) during the reporting month.


the validated data to the Business Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions The number of people who received specialist palliative care services (home care) in the community in the reporting month.

9 Minimum Data Set The number of people who received specialist palliative care services (home care) in the community in the reporting month.

















reports ?










Specialist Lead

3

6



1 KPI Title Number of new patients seen by specialist palliative care services in their normal place of residence.

2 KPI Description This is a count of the number of new (first time ever) patients seen by the specialist palliative care (home care) team in the community during

the reporting month A patient can only be 'new' on the first time referred. Each patient is counted once only. Patients discharged and then re-

referred, regardless of timeframe, are not to be considered a new patient but a re-referral. Home is defined as the patient's normal place of

residence i.e. where he / she lives, and may include his / her home, carers home, nursing home, community nursing unit, community hospital,

district hospital etc.

KPI Rationale To determine the number of new patients in receipt of specialist palliative care in the community during the reporting month. This will inform

service delivery and decisions with regard to service provision / prediction of service provision.


two).




CHO 1 - 900, CHO 2 - 1,120, CHO 3 - 910, CHO 4 - 1,550, CHO 5 - 1,050, CHO 6 - 830, CHO 7 - 940, CHO 8 - 1,360, CHO 9 - 950

5 KPI Calculation Count all new people who were seen by the specialist palliative care team for the first time ever in their normal place of residence in the

community in the reporting month.


the validated data to the Business Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions New patients seen for the first time ever in their normal place of residence by the specialist palliative care team.

9 Minimum Data Set New patients seen for the first time ever in their normal place of residence by the specialist palliative care team.

















reports ?









6



Specialist Lead

3


1 KPI Title No. of children in the care of the children's outreach nurse

2 KPI Description This is a count of the total number of children who were on the active patient list of the children's outreach nurse (clinical nurse co-ordinator) in

the reporting month. It includes children on the list on the first day of the month plus new children plus transfers accepted and receiving active

care during the reporting month.

KPI Rationale To determine the number of children / families being supported by the service and to assist in service planning.


☑ Person Centred Care, ☑Effective Care □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce,

□ Use of Resources, □ Governance, □ Leadership and Management

4 KPI Target 2017 NSP 2017 Target National - 269


5 KPI Calculation Count the total number of children in the active care of the children's outreach nurse (clinical nurse co-ordinator) during the reporting month.

Data Source Data is sourced by the children's outreach nurse (clinical nurse co-ordinator) who submits it to the Business Information Unit (BIU) Community

Healthcare Team.





8 Tracer Conditions The number of children in the active care of the childrens outreach nurse (clinical nurse co-ordinator) in the reporting month.

9 Minimum Data Set The number of children in the active care of the childrens outreach nurse (clinical nurse co-ordinator) in the reporting month.



oDaily oWeekly ☑Monthly oQuarterly oBi-annually oAnnually oOther – give details:

Data is monitored by the children's outreach nurse (clinical nurse co-ordinator) and the National Lead for Palliative Care.











15 KPI is reported in which reports

?





Information Analyst : Geraldine Littler, Business Information Unit- Palliative Care & Social Inclusion, Planning and Business Information (PBI)

046 9251330 Email:[email protected]



6


Specialist Lead

Primary Care - Palliative Care Children's Palliative Care Services

3

1 KPI Title No. of new children in the care of the children's outreach nurse

2 KPI Description This is a count of the number of new children seen face to face, for the first time ever, by the childrens outreach nurse (clinical nurse co-

ordinator) in an acute hospital setting and in the home, in the reporting month. Each new child is counted once only when initially seen on first

face to face contact.

KPI Rationale To determine the number of new children / families being supported by the service and to assist in service planning.


☑ Person Centred Care, ☑Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □ Use of

Resources, □ Governance, □ Leadership and Management

4 KPI Target 2017 NSP 2017 Target - to be set

5 KPI Calculation Count the total number of children in the care of (seen by) the childrens outreach nurse (clinical nurse co-ordinator) in an acute hospital setting

and in the home in the reporting month. For children seen in the home, data is returned by the Local Health Office (LHO) address of the child.

Data Source Data is sourced by the childrens outreach nurse (clinical nurse co-ordinator) who submits it to the Business Information Unit (BIU) Community

Healthcare Team.





8 Tracer Conditions The number of new children seen by the childrens outreach nurse for the first time ever during the reporting month.

9 Minimum Data Set The number of new children seen by the childrens outreach nurse for the first time ever during the reporting month.













☑ National ☑ CHO □ LHO Area □ Hospital



?


☑ Performance Report (NSP) □Other – give details:





National Lead: Sheilagh Reaper-Reynolds Email: [email protected] John Hennessy, National Director, Primary Care Division, Health Service Executive. National Director and Division

6


3


Specialist Lead

1 KPI Title Number of children in the care of the specialist paediatric palliative care team in an acute hospital setting in the month

2 KPI Description This is a count of the total number of children who received care from the Specialist Paediatric Palliative Care Teams in Our Lady's Children's

Hospital Crumlin and Children's University Hospital Temple Street during the reporting month.

The Specialist Paediatric Palliative Care Teams in Our Lady's Children's Hospital Crumlin and Children's University Hospital Temple Street

provide care to children in the hospital and support to former patients and their families living at home. The total number of children recorded at

Our Lady’s Children’s Hospital, Crumlin and Children's University Hospital Temple Street include all children under the care of the Consultant

Paediatrician with a Special Interest in Palliative Medicine and may be resident anywhere in the country.

KPI Rationale To determine the number of children / families being supported by the service and to assist in service planning.


☑ Person Centred Care, ☑Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce,

□ Use of Resources, □ Governance, □ Leadership and Management

4 KPI Target 2017 NSP 2017 Target - 20

Our Lady’s Children’s Hospital, Crumlin - 20

Children's University Hospital Temple Street to be set in 2017.

5 KPI Calculation Count the total number of children in the care of the specialist palliative care teams Our Lady's Children's Hospital Crumlin and Children's

University Hospital Temple Street in the reporting month.

Data Source Data is sourced by the Specialist Palliative Care teams who submit it to the Business Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions Children in the care of the specialist palliative care teams Our Lady’s Children’s Hospital, Crumlin and Children's University Hospital Temple

Street in the reporting month.

9 Minimum Data Set Children in the care of the specialist palliative care teams Our Lady’s Children’s Hospital, Crumlin and Children's University Hospital Temple

Street in the reporting month.

10 International Comparison No+C67









□Quarterly in arrears (quarter 1 data reported in quarter 2)

□Rolling 12 months (previous 12 month period)


☑ National □ CHO □ LHO Area ☑ Hospital



?










Specialist Lead

6

3


1 KPI Title Number of children in the care of the specialist paediatric palliative care team in an acute hospital setting

2 KPI Description This is a count of the total number of new children seen for the first time ever by the Specialist Paediatric Palliative Care team during the

reporting month. Each new child is counted once only when initially seen on a first face to face contact.

KPI Rationale To determine the number of new children / families being supported by the service and to assist in service planning.


☑ Person Centred Care, ☑Effective Care, □Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □ Use of

Resources, □ Governance, □ Leadership and Management

4 KPI Target 2017 NSP 2017 Target - 63

Our Lady’s Children’s Hospital, Crumlin - 63

Children's University Hospital Temple Street to be set in 2017.

5 KPI Calculation Count the total number of new children in the care of the Specialist Palliative Care Team in Our Lady's Childrens Hospital Crumlin and Children's

University Hospital Temple Street seen for the first time ever during the reporting period.

Data Source Data is sourced by the specialist palliative care teams who submit it to the Business Information Unit (BIU) Community Healthcare Team.





8 Tracer Conditions New children seen for the first time ever by the specialist palliative care teams in Our Lady’s Children’s Hospital, Crumlin and Children's

University Hospital Temple Street

9 Minimum Data Set New children seen for the first time ever by the specialist palliative care teams in Our Lady’s Children’s Hospital, Crumlin and Children's

University Hospital Temple Street
















?









3


Specialist Lead


6

1 KPI Title Number of new referrals for inpatient services seen by the specialist palliative care team

2 KPI Description This is a count of the total number of new patients referred for inpatient palliative care services seen for the first time ever (new referrals)

by the specialist palliative care team, as an inpatient or an outpatient in an acute hospital setting, during the reporting month. A patient

can only be 'new' on the first time referred. Patients discharged and then re-referred, regardless of timeframe, are not to be considered a

new patient but a re-referral. Care provided by the specialist palliative home care team who work in an acute hospital is not included.

Rationale To determine the total number of patients (new referrals) seen by the specialist palliative care team in the reporting month and demand for

these services.Indicator Classification Please tick which Indicator Classification this indicator applies to, ideally choose one classification (in some cases you may need to

choose two).

☑ Person Centred Care, ☑Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □ Use

of Resources, □ Governance, □ Leadership and Management


CHO 1 - 874, CHO 2 - 1,564, CHO 3 - 878, CHO 4 - 2,064, CHO 5 - 966, CHO 6 - 984, CHO 7 - 1,976, CHO 8 -1,258, CHO 9 - 1,736

5 KPI Calculation Count the total number of new patients referred for inpatient palliative care services seen for the first time ever by the specialist palliative

care team in an acute hospital setting, in the reporting period.

Data Source Data is sourced by the specialist palliative care teams in acute hospitals who submit the validated data to the Business Information Unit

(BIU) Community Healthcare Team.





8 Tracer Conditions New patients referred for inpatient palliative care services seen by the Specialist Palliative Care Team in an acute hospital setting in the

reporting month.

9 Minimum Data Set New patients referred for inpatient palliative care services seen by the Specialist Palliative Care Team in an acute hospital setting in the

reporting month.




Data is monitored by the Specialist Palliative Care team, hospital management and the National Lead for Palliative Care. 12 KPI Reporting Frequency Indicate how often the KPI will be reported:






□ Rolling 12 months (previous 12 month period)14 KPI Reporting Aggregation Indicate the level of aggregation – for example over a geographical location:



?









Primary Care - Palliative Care Acute Services Palliative Care


3

6


Specialist Lead

1 KPI Title Specialist palliative care services provided in the acute setting to new patients and re referral within two days

2 KPI Description This is a count of the total number of patients i.e. new patients (seen for the first time ever) and patients re referred to the specialist

palliative care services, that were seen by the specialist palliative care team in an acute hospital setting (on an out-patient or inpatient

basis), within two days of referral. The wait time (number of days on a full Monday to Sunday seven day service basis) to be seen is

counted from the date of referral to the date the patient is actually seen.

Rationale To determine the wait times for patients to be seen by the specialist palliative care team.


choose two).

☑ Person Centred Care, ☑Effective Care, □ Safe Care, □ Better Health and Wellbeing, □ Use of Information, □ Workforce, □ Use

of Resources, □ Governance, □ Leadership and Management


CHO 1 - 724, CHO 2 - 1,934, CHO 3 - 846, CHO 4 - 2,056, CHO 5 - 1,576, CHO 6 - 1,522, CHO 7 - 1,812, CHO 8 - 1,372, CHO 9 -1,678

5 KPI Calculation Count the total number of patients (new patients and re-referrals) seen by the specialist palliative care team in an acute hospital setting,

within two days of referral.

Data Source Data is sourced by the specialist palliative care teams in acute hospitals who submit the validated data to the Business Information Unit

(BIU) Community Healthcare Team.





8 Tracer Conditions Number of patients seen within two days of referral by the specialist palliative care team in an acute hospital setting in the reporting period

9 Minimum Data Set Number of patients seen within two days of referral by the specialist palliative care team in an acute hospital setting in the reporting

period.




Data is monitored by the Specialist Palliative Care team, hospital management and the National Lead for Palliative Care. 12 KPI Reporting Frequency Indicate how often the KPI will be reported:






□ Rolling 12 months (previous 12 month period)14 KPI Reporting Aggregation Indicate the level of aggregation – for example over a geographical location:

☑ National ☑ CHO □ LHO Area ☑ Hospital


?










Specialist Lead

3


6

Primary Care - Palliative Care Acute Services Palliative Care

palliative care key performance indicator metadata 2017 · data quality issues data quality issues...

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